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Postoperative tracheal rupture in a patient with a difficult airway

[Rupture postopératoire de la trachée chez un patient difficile à intuber]

From the Department of Anesthesia, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.

Address correspondence to: Dr. Peter C. MacDougall, Department of Anesthesia, University Health Network, Toronto General Hospital, 200 Elizabeth Street, Eaton North Wing, 3rd Floor, Room 424, Toronto, Ontario M5G 2C4, Canada. E-mail: pcmacdou{at}dal.ca

Purpose: Tracheal rupture is an uncommon and potentially life-threatening event. This report presents a case of postoperative tracheal rupture in a patient with a known difficult airway presenting to a rural hospital.

Clinical features: A 29-yr-old man presented to a rural hospital with sudden onset neck pain and progressive dyspnea. Five days earlier the patient had undergone tracheal resection for tracheal stenosis related to prolonged intubation. The patient informed the emergency room staff that the attending anesthesiologist had made note of a "difficult airway". The community hospital had neither a portable storage unit for difficult airway management nor a bronchoscope available. In the presence of a general surgeon, an initial attempt at an awake intubation was unsuccessful. During this time the patient developed massive subcutaneous emphysema obliterating surgical landmarks and causing stridor. A modified rapid sequence intubation was performed. Intubation was successful using a Jackson-Wisconsin #3 straight blade and styletted endotracheal tube. The patient was transferred to a tertiary care centre where he underwent a primary repair of the trachea.

Conclusion: Management of tracheal rupture in the patient with a difficult airway is a challenging problem, especially, in a rural hospital. This case highlights the need for skilled staff and resources to manage a difficult airway in the emergency room.